Professional Employment Application

SECTION 1: APPLICANT INFORMATION
Full Legal Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Date
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
E-mail Address:*
Company WebsiteSchool/University ContactCommunity EventJob FairAdvertisementOther
SECTION 2: POSITION
Position Applying For:*
If "Other" - Position Applying For:
Desired Hourly Rate:*
Bachelor's-Level Behavioral Health ProfessionalLimited Licensed ClinicianFully Licensed ClinicianAdministrative / Office SupportMaster's-Level Behavioral Health ProfessionalOther
Date Available to Start*

MonthDayYear
Date
Dates/Times Unavailable
10–15 hours per week16–20 hours per week21–25 hours per week26–30 hours per weekFlexibleOther
Early Childhood (ages 3–6)Children (ages 7–12)Teens (ages 13–17)Young Adults (ages 18–25)AdultsComfortable with all age groups
SECTION 3: EDUCATION
HIGH SCHOOL/GED:
High School Name or GED:*
City, State:*
Year:*
COLLEGE/UNIVERSITY:

(if applicable)
College/University:*
Years Attended:*
Degree Received:*
Major:*
Clinical License Information (If Applicable):
License Type (LPC, LMSW, LMSW-C, LLP, LMFT, LP, etc.)License NumberState IssuedExpiration Date
College/University:
Years Attended:
Degree Received:
Major:
Certifications, Licenses, Additional education, Trainings, etc:
SECTION 4: EXPERIENCE & SKILL AREA

Check areas relevant to your background:
School-Based ServicesHome/Community-Based ServicesI/DD PopulationSED PopulationBehavioral InterventionIndividual CounselingGroup FacilitationSkill-Building / CLSDocumentation & Case NotesTrauma-Informed PracticesIEP Collaboration
Scheduling & calendar managementData entryClient communicationRecord keeping & complianceEmployee communicationDocumentation & Progress Notes
SECTION 5: EMPLOYMENT HISTORY
EMPLOYER #1*
Rows Date Started Date Ended

Dates worked for
Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary/Hourly pay: *
Supervisor Name & Contact:*
EMPLOYER #2*
Rows Date Started Date Ended

Dates worked for
Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Salary/Hourly rate:*
Supervisor Name & Contact:*
SECTION 6: BACKGROUND
YesNo
If yes, explain:
Criminal background checkRequired onboarding and compliance trainingsCompliance with HIPAA and FERPAFingerprinting (if required)School district onboarding requirements (if assigned to a school-based role)
SECTION 7: REFERENCES
Reference #1 (Name & Phone Number):*
Reference #2 (Name & Phone Number):*
Reference #3 (Name & Phone Number):
SECTION 8: CERTIFICATION
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation may result in disqualification from employment or termination if hired.
Name:Date:
SECTION 9: RESUME UPLOAD
UPLOAD RESUME: If you have trouble uploading documents, email document(s) to hr@rbcsupportservices.org

Upload a File

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ADDITIONAL INFORMATION:
Thank you for taking time to complete this job application. We will be in contact with you shortly. We look forward to you potentially becoming part of the RBC Support Services Family.

Email: hr@rbcsupportservices.org

Phone: (248) 396-7589

Website: www.rbcsupportservices.org
Should be Empty:

Rows	Date Started	Date Ended
Dates worked for

Rows	Date Started	Date Ended
Dates worked for

SECTION 1: APPLICANT INFORMATION

SECTION 2: POSITION

SECTION 3: EDUCATION

HIGH SCHOOL/GED:

COLLEGE/UNIVERSITY:

SECTION 4: EXPERIENCE & SKILL AREA

SECTION 5: EMPLOYMENT HISTORY

SECTION 6: BACKGROUND

SECTION 7: REFERENCES

SECTION 8: CERTIFICATION

SECTION 9: RESUME UPLOAD